When Beth Kennedy's head hit the ice hard, she was stunned. The teen got up slowly, skated to her hockey team's bench and asked her rec league coach if she could sit out for a bit. But she returned to the heat of the tournament game a few minutes later.

"As soon as it ended and I took my helmet off, I had this surging headache," Beth says of the March game.

Still, no one questioned whether she had a concussion. Her mother, sitting high in the stands, didn't see what had happened when her daughter collided with another player, and she didn't recognize the warning signs of a brain injury.

So, despite the headache, Beth — one of hundreds, perhaps thousands, of Maryland youngsters to suffer sports-related brain injuries this year — played again the next day for the York Lady Ice Devils in a tournament sponsored by the Baltimore Youth Hockey Club.

With national attention on the issue of concussions in the NFL, Marylanders are wrestling over the protocols needed to reduce such injuries, which can cause lasting brain damage. The state does not have statistics on the scope of the problem, but nationally 248,000 people under age 19 were treated in emergency rooms in 2009 for a sports-related nonfatal traumatic brain injury, according to the Centers for Disease Control and Prevention.

Over the next several months, a task force created by the Maryland state school board will gather research and public comment as it considers new regulations to prevent concussions. School board members say they will not shy away from taking unpopular steps, including placing limits on practices in football or other sports.

Meanwhile, the national governing body for youth football recently launched Heads Up Football, a resource for parents, coaches and players on concussions and related issues. The NFL and its partners also have committed about $1 million to provide new helmets to youth football players in low-income communities.

The state board approved emergency rules in July requiring that coaches be trained and parents receive information about concussions. Students also must be removed from a game if the coach suspects a concussion and aren't allowed back in until they have been cleared by a medical professional.

Private schools are likely to follow the state's rules, said Rick Diggs, executive director of the Maryland Interscholastic Athletic Association. Recreational league games played on public school grounds will also come under the newregulations.

Still, there is a wide disparity in the way concussions are addressed — even among Maryland localities. And while experts say there is general agreement about the assessment and treatment of concussions, Beth and her mother say they were uninformed about how devastating a concussion could be and how it should be treated.

After getting hurt, Beth felt half-removed from the world. Concentrating on homework or in class at Maryvale Preparatory School gave her a headache. Even engaging in teenage chatter with friends made her feel ill. After school, she would sleep until 9 p.m, have dinner and sleep until morning.

Sharon Kennedy said Maryvale's athletic trainer finally diagnosed Beth's concussion, in part by comparing results on memory and mental agility tests, and referred her to a doctor. "The tough thing about this is it is not a skinned knee that needs stitches," she said.

Beth's recovery took months. Only recently did she take a hockey stick in her hands to practice again, the first time she had been allowed to play since the St. Patrick's Day injury.

Beth knows she was lucky that she wasn't hit again during the tournament, because another blow to her head could have had devastating consequences. Players who suffer a second concussion before the first one is healed can endure long-term effects.

Derek Sheely, a Frostburg University football player, died last August during preseason training after he sustained what doctors believe were two concussions in a matter of days. Derek had never had a documented concussion before he went to college last year, according to his mother, Kristen L. Sheely.

The Sheelys talked to their son the night before the second concussion, and he sounded fine and didn't mention an injury. The next day they were racing to a hospital.

He was hit, ran off the field and then ran another play. He "ran to the sideline and said he didn't feel well. He went down to his knees, and he didn't get up. They called 911," Kristen Sheely said. After two operations, Derek died about a week later.

"It is still unbelievable to us. ... This shouldn't have happened," she said.

The Sheelys have set up a foundation to help educate people about concussions. "I don't want to put children in bubbles, but I think you need to be smart and you need to be educated. I would give anything to have Derek back," she said.

'Using your brain hurts it'

While a death is rare, said Christopher Vaughan, a neuropsychologist at the Children's National Medical Center in D.C. who also works in a Towson clinic, lots of high school students are being injured playing sports.

When a concussion is suspected, state public school regulations say, the student must be taken out of the game and not allowed back until cleared by a physician or medical professional.

Bill Rudow, whose son, Michael, was injured in an April 2011 game while playing lacrosse for Friends School in Baltimore, said the best information he got about concussions did not come from a pediatrician, but from a specialist.

Rudow, who is trained as a first responder, said he would have kept his son home from school and not allowed him to exercise, listen to music, watch television or read, if he had more knowledge about the healing process.

"I had no idea that using your brain hurts it. We didn't realize that he should have been resting and doing absolutely nothing those first couple of days," he said.

Michael, injured as a junior, continues to have headaches and has decided to delay his entrance into the University of Pennsylvania for a year to try to heal.

"My junior year was marked by feeling slow, fatigued and generally out of it," said Michael, 18. He missed about a day of school a week, and after resting over the summer, began to feel a little better. But during his senior year he had excruciating headaches whenever he extended himself with homework. He gave up lacrosse.

"Athletes are told to fight through pain," he said. "I didn't go back in to play, but I think that a lot of kids would go back in not knowing."

Michael believes that beginning in elementary school, athletes should be taught how serious concussions are so they will be alert to the symptoms and seek help immediately.

'Stress the mental portion'

One step the state school board is considering is placing limits on practices. Ivy League universities have recently placed limits on contact practices in football, lacrosse and soccer. The NFL and the association for little league football have taken similar steps.

The Baltimore Youth Hockey Club, which was hosting the tournament in which Beth Kennedy was playing, does not have mandatory testing; its coaches, however, must be certified by USA Hockey, which includes a concussion component in its training.

The rules for deciding when athletes must be taken out of play, when they can return and who makes those calls are not consistent throughout youth hockey leagues, said Charles Kaplan, president of the club, a recreational and travel league with 300 players.

"It is an area we probably need to address. We are faced with the same challenges that other programs are," he said.

Kaplan said that his club works with Lifebridge Health to provide a card to all its coaches with a set of questions they are required to ask players to help evaluate them if they suspect they have a concussion. It also offers baseline testing as an option for parents.

In addition, they provide "impact stickers" to put on the helmets of the members of its travel teams; if the seal is broken, indicating an abnormal impact has occurred, the player has to come off the ice.

Howard is one of the counties that is tracking the number of concussions. Mike Williams, Howard County's athletic coordinator, said that when the county started counting concussions in 2007, there were 72 documented cases. This past year there were 275.

"Those concussions were always there, but we didn't have the education and awareness we do now. We are able to better document it," he said.

Last year, Howard football teams began limiting the number of times a week players could have full contact practice. They're also cutting back on drills that put kids at greater risk.

Those limits didn't seem to hurt the teams. "We are winning state championships doing it our way," Williams said. "In football, you can't prevent them all. What you want to do is keep the numbers as minimal as possible."

Kyle Schmitt, the coach at Atholton High School, has an even more conservative approach to training and only has his kids wear full gear once a week. "We limit hitting. We just don't beat our kids up," he said. "We stress the mental portion of the game rather than knocking heads."

Howard, Anne Arundel, Harford and Carroll counties have an athletic trainer in every school. Howard, Harford and Carroll require students playing a contact sport, such as lacrosse, soccer and football, to take a memory and mental agility test that can be used as a comparison later if a concussion is suspected. But those efforts are ahead of other school systems.

Baltimore City, for example, does not have trainers in every school. In Baltimore County, there is one trainer for every two or three schools, although a trainer attends every game of contact sports, according to Dale Rauenzahn, executive director of student support services.

Most private schools have full-time athletic trainers, Diggs said, and the MIAA encourages schools to do baseline testing that helps evaluate if a student has suffered a concussion.

Call for more education

Sharon Kennedy said parents need more educational materials; she got one sheet that outlined concussion symptoms. Such information is given to Maryland public school parents, but Kennedy says videos and other information could be distributed at Meet the Coaches nights and posted on school websites.

Some school systems are already taking those steps. Anne Arundel handed out 30,000 refrigerator magnets last year that list the signs of a concussion, said Greg LeGrand, coordinator of athletics in Anne Arundel County.

Schools have to be agile in a response, because sometimes students may need to stay out of school for days or only come to class for short periods, said Vaughan, the neuropsychologist.

"School plays such a vital role in supporting recovery," he said. "There are some that are incredibly supportive and have outstanding communication and policies in place and there are others where it is really a challenge to get support and get modification to a student's schedule."

As frightening as her experience was, Beth, who is attending Towson University this fall, is eager to return to playing in a league. She said, "I don't know who I would be if I didn't play ice hockey."

An earlier version of this article misstated that Beth Kennedy was playing for the Baltimore Youth Hockey Club when she was injured; she was playing for another team and league in a tournament sponsored by that club. In addition, coaches in the Baltimore Youth Hockey Club must be certified by USA Hockey, which includes a concussion component in its training.

Concussion symptoms

Headache or pressure in the head

Nausea or vomiting

Balance problems or dizziness

Double or blurry vision

Sensitivity to light or noise

Feeling sluggish, hazy or groggy

Confusion

Concentration or memory problems

Source: Centers for Disease Control and Prevention

Steps being taken

Athletic groups across the country have taken steps to protect athletes from traumatic brain injuries:

•Ivy League universities have recently placed limits on contact practices in football, lacrosse and soccer. The NFL and the association for little league football have taken similar steps.

•The national governing body for youth football recently launched Heads Up Football, a resource for parents, coaches and players on concussions and related issues.

•The NFL and its partners have committed about $1 million to provide new helmets to youth football players in low-income communities.

Ben Matthews (left) and Ryan Simonds drill on the first day of pre-season practice for the Atholton High School football team. Kyle Schmitt, the coach at Atholton, has a conservative approach to training and only has his kids wear full gear once a week. “We limit hitting. We just don’t beat our...

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